Cataract versus combined surgery in pseudoexfoliation glaucoma

Abstract

Purpose: Pseudoexfoliation glaucoma (XFG) is often associated with a higher rate of intraoperative complications and failure. This study aims to compare the long-term clinical and surgical outcomes of cataract surgery alone versus combined surgery in XFG.

This was a retrospective: comparative case series.

Methods: All patients with XFG who underwent either cataract surgery alone [group 1: either phacoemulsification, PHACO/small-incision cataract surgery (SICS), n = 35] or combined surgery (group 2: phacotrabeculectomy, PHACOT or SICS + trabeculectomy, n = 46) from 2013 to 2018 by a single trained surgeon were screened and recalled for a detailed clinical examination, including Humphrey visual field analysis at 3-monthly intervals for a minimum of 3 years. Surgical success (intraocular pressure, IOP, <21 mm Hg and >6 mm Hg with (qualified success) or without medicines, complete success, survival rates, visual field changes, and need for additional procedures/medicines for IOP control were compared between groups.

Results: A total of 81 eyes of 68 patients with XFG were included in this study (groups 1-35 eyes and groups 2-46 eyes each). Both groups achieved 27-40% IOP reduction from preoperative IOP levels, P < 0.001. Surgical success rates were similar in both groups (complete success 66% vs 55%, P = 0.4), qualified success 17% vs 24%, P = 0.8, in groups 1 and 2). Kaplan-Meier analysis showed a marginally better survival rate for group 1, 75% (55-87%), than group 2, 66% (50-78%), at 3 and 5 years which was not significantly different. The number of eyes that progressed at 5 years after surgery (5-6%) was similar in both groups.

Conclusion: Cataract surgery can be as effective as combined surgery in XFG eyes with regards to final visual acuity, long-term IOP profile, and visual field progression, and complications/survival rates are comparable between the two procedures.

Keywords: Complications in pseudoexfoliation; phacotrabeculectomy; pseudoexfoliation glaucoma; small-incision cataract surgery; surgical success.

Figure 1

Intraoperative photographs showing the surgical steps of phaco-trabeculectomy. (a) A fornix-based conjunctival flap is made and a partial thickness triangular scleral flap (3 × 3 mm) is created, (b) diffuse and posterior application of MMC (0.2 mg/ml, for 3 min), (c) phacoemulsification by the phaco-chop technique, (d) foldable IOL implantation, (e) creation of trabeculectomy ostium (1.5 mm × 1.5 mm), (f) peripheral basal iridectomy, (g) closing scleral flap, and (h) the conjunctival closure by wing sutures (i) ensuring diffuse bleb formation

Figure 2

Box plot of intraocular pressure after cataract (group 1) or combined (group 2) surgery in eyes with pseudoexfoliation glaucoma—see text for the detailed description of groups

Figure 3

Kaplan–Meier survival curves for eyes with pseudoexfoliation glaucoma after cataract (group 1) or combined (group 2) surgery—See text for the detailed description of groups